CHRONIC HYPERTENSION

PLEASE RESPOND TO THE FOLLOWING POST IN AGREEMENT TO HER DIAGNOSIS OF CHRONIC HYPERTENSION.

 

 

Lisa’s Post

Week 8 Discussion main post

 

Patient Information:

Initials: K.B.   Age: 36   Sex: female   Race: African American

S.

CC (chief complaint): Blood pressure is a “little higher than it should be” 

HPI: K.B. is a 36-year-old African American female who presents to her local urgent care with a headache and stating her mother took her blood pressure and it was a “little higher than it should be.” She has had an unremarkable pregnancy and conceived through IVF. Currently she is 30 5/7 weeks pregnant and states she has had no problems with her pregnancy. She relates she was on hctz prior to her pregnancy for borderline BP but stopped it when she underwent IVF and her blood pressure remained “pretty normal.” She relates she was prescribed labetalol but does not take it regularly as she does not want to take anything that might hurt the baby. She relates she has felt fetal movement within the past hour. Prenatal screening included initial lab and third trimester CBC and glucose testing normal. First prenatal visit had baseline PIH due to history of hypertension, normal at visit including normal protein to creatine ratio.

Current Medications:

Prenatal vitamins

HCTZ prior to pregnancy

Labetalol but does not take regularly

Allergies: NKDA, environmental or food allergies.

PMHx: All immunizations are up to date and she had her tetanus shot one year ago. IVF procedure. HypertensionSoc & Substance Hx: This case study does not state her social or substance history. Questions related to her social and substance history should be asked as part of the history taking process.

Fam Hx: No family history included in this case study, but it is an area that should be covered with her current condition and high blood pressure. Questions about her family history including her grandparents, parents and siblings’ medical conditions.

Surgical Hx: no prior surgeries

Mental Hx: There is no mention of mental history in this case study. Being pregnant with her first child and having IVF she is subject to anxiety and stress which could contribute to her high blood pressure. Hormonal changes can also cause depression.  

Violence Hx: There is no mention of any violent history.

Reproductive Hx: G1 P0. No further information provided in the case study as to when she started her menses, how her flow is and anything related to her sex life.

ROS:

Vital Signs: BMI 25.1; weight gain to date 17 lbs; BP 162/90-pulse 82-respirations 16 and unlabored-temp 98.2 orally.

K.B. is in the emergency room sitting on the exam table looking comfortable and in no distress. She is dressed appropriate for the weather, is clean and appears well nourished. Was transferred to emergency room 30 minutes prior for her complaints and her gestational age. Repeat BP 166/88, 15 minutes later 162/92. All blood pressures where taken manually.

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, or double vision. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: last menstrual period was prior to pregnancy

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: G1 P0 via IVF. Is 30 5/7 weeks fetal movement felt within the last hour. No leaking fluids, vaginal bleeding, or contractions.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

HEENT: Eyes with no discharge or redness, no swelling of neck and no distention of jugular veins.

Cardiovascular: no murmur, S1 S2 noted, no gallop, regular rhythm current blood pressure 140/88 after 2 doses of hydralazine and one dose of po nifedipine.

Respiratory: lungs clear to auscultation; breathing is non labored.

Gastrointestinal: Abdomen round and movement of fetus is noted, bowel sounds present in all 4 quadrants. No tenderness with palpation. Fetal heart tones present.

Diagnostic results:

Lab results:

WBC

10.92

RBC

3.63

Hgb

10.4

Hct

32,5

Plts

238

Glucose

98

Sodium

144

Potassium

3.9

BUN

9

Creatinine

0.64

ALT (SGPT)

96

AST

75

Alk Phos

187

aPTT

26.9

Fibrinogen

650

Uric acid

3

Urine protein/Cretinine ratio

0.11

 

 

 

This patient has a history of high blood pressure per her medical records, the severity and type of hypertension needs to be determined. It is advisable to rule out the existence of any associated pathology so a complete analysis with evaluation of kidney function and proteinuria, liver function tests and coagulation tests as well as fundus and ECG should be performed.

Differential Diagnoses:

Chronic hypertension: This diagnosis is evidenced by the presence of a history of hypertension with blood pressure elevation that is persistent greater than or equal to weeks postpartum and by the lack of evidence of proteinuria to make a diagnosis of pre-eclampsia

Pre-eclampsia: The patient does not have pre-eclampsia as evidenced by lab results indicating no proteinuria, no end-organ dysfunction development, no presence of new onset of cerebral or visual disturbances. No pulmonary edema noted.

Eclampsia: This diagnosis is rare and is a severe complication of pre-eclampsia in which the high blood pressure results in seizures during pregnancy. This is not the diagnosis as noted by lack of evidence for swelling in face or hands, headaches, excessive weight gain, nausea and vomiting, vision problems, difficulty urinating and abdominal pain especially in the right upper abdomen.

Plan:

Patient to be admitted for further diagnostic studies. Vital signs to monitored, laboratory test that include proteinuria, kidney and liver function as well as platelets. Monitoring of fetal growth and well-being. Pharmacological management of blood pressure with labetalol.

Education is to warn her of the need to take the antihypertensive medications during pregnancy, to call her for regular check-ups more frequently and to monitor blood pressure and fetal well-being.